Probing what information is available about the current status of placement or accommodation and level of personal healthcare available to mentally impaired and emotionally disturbed individuals, it is clear that the analysis is as diverse as there are different mental illnesses. While statistics on managed care treatment for people with severe and disabling mental illnesses are sparse, it is evident that the financial responsibility to care for and house these patients is enormous.

According to Dr. David Satcher, the Surgeon General (1999), approximately 20% of the U.S. adult population has a mental illness. He says, "These illnesses include anxiety disorders, mood disorders, anorexia nervosa, and severe cognitive impairment. More serious mental illnesses include Bipolar disorder and schizophrenia. Mental illness accounts for 15% of overall burden of disease -- more than malignant cancer and respiratory diseases -- and as far back as 1996 the direct cost of mental illness to Americans was already $69-billion." (UMASS)

A more recent study states that "approximately one in three Americans will experience some form of mental disorder at some point in their lives, and according to one estimate, one in every 6.4 adults is currently suffering from some form of mental illness. This figure comes to 41.2 million people and climbs higher if substance abuse is included. A significant number of these - more than 1.7 million Americans - suffers from a persistent and severely disabling condition, such as schizophrenia. The costs of caring for these patients and those whose illness is episodic, curable, or only mildly debilitating have reached $136.1 billion per year." (Callahan)

Reform within the health care system for the mentally disabled is, according to many experts, a very serious issue that urgently needs to be addressed. "Given the past and present dismal plight of mental health services, both its patients and its providers have good reason to be concerned about reform. Historically, mental health services have not received the same support as physical health services. Private and public funding permit "carve outs" in mental health coverage that provide fewer benefits than those allowed for physical health. Private insurance customarily restricts mental health benefits more stringently, setting caps on numbers of hospital days or outpatient visits, or imposing annual or lifetime dollar limits for mental health services. (Ibid)

The situation is highlighted by many incongruities and anomalies in relation to other health care sectors. Insurance policies, for example, typically limit hospital care for persons with mental illness to thirty days. Other common examples are the fact that psychotherapy sessions are generally limited to ninety visits a year with a 50% co-payment; and health maintenance organizations (HMOs) customarily restrict therapy to thirty sessions a year with a 50% co-payment. (ibid)

What are the reasons for the unequal treatment of mental health patients? Part of the reason lies in biases and prejudices, as well as lack of knowledge relating to mental disorders. One of the central reasons for this lack of knowledge is due to the fact that mental illness is poorly defined. "While few would argue today that mental illness is a myth, or maintain that mental illness is whatever psychiatrists treat, nonetheless there is a bewildering diversity of views about mental illness, ranging from biological accounts to social determinism" ( ibid)

The situation and issues

Social work - which is at the heart of the healthcare industry - has a commitment to vulnerable populations and has a responsibility not to subject them to greater vulnerability by taking away certain services due to cost-cutting and corporate oligopoly. With this in mind, one needs to consider how a community will be affected when cash-strapped agencies stop promoting important activities such as educating people in the prevention and treatment of mental illnesses. Also, even though larger corporations may have little connection to the local community, the continual buying, selling and merging of large national corporations in the healthcare business directly impact on the states' administration of mental health programs. Does this mean that states will be obliged to turn to the few managed care corporations -- even if they are costlier -- to provide essential services to vulnerable citizens? And how will control be exercised to ensure that service quality is maintained?

Firstly, something of the background of the health care landscape needs to be understood. The situation with regard to health care is outlined in the following: "Although the cost of health care has grown to 12% of the gross national product (Dorwart, 1990), only 12% to 14% of total health care dollars are for mental health services. The total estimated spending on mental health services, both public and private, was approximately $42.5 billion in 1990 (Medicaid and Mental Health, 1995). The pattern of use by mental health care consumers is not unlike that of users of physical health care - about 10% of mental health care users account for about 50% of all outpatient expenditures (Durenberger, 1989), and another 10% account for 60% of the inpatient days (Scharfstein & Beigel, 1985). In private health insurance plans, mental health care represents no more than 25% of total health care costs (Levin, 1992)." (Rose & Keigher, 1996)

Managed Behavioral Health Care

A crucial aspect with regard to the care of mentally ill patients is the recent emergence of an oligopoly among the key corporate players in the managed behavioral health care agenda. "The vendors with the largest total enrollment at the beginning of 1995 were Human Affairs International, Medco Behavioral Health Care, Value Behavioral Health, and Green Spring Health Services. These four managed care organizations are responsible for directing the care of over 51 million "covered lives" (individuals who are eligible for care under specific care plans financed either by employers or by some type of public funding) - 47% of the market. With a total enrolment of 111-million people, 40 of the largest managed behavioral health program vendors reported total annual revenues of approximately $2.1-billion." (Oss, Winters, Stair, & Mackie, 1995). (Rose & Keigher, 1996)

Where do patients receive appropriate healthcare? Some day hospitals provide treatment for elderly patients suffering from organic illnesses such as Alzheimer's disease and functional illnesses such as depression and schizophrenia. Both non-elderly and elderly patients who are dependent and behaviorally disturbed are increasingly entering nursing homes, which are generally stand-alone facilities, but some are operated within a hospital or retirement community. While the level of care provided by nursing homes has increased significantly over the past years, many now also focus their attention on rehabilitation, which means patients can return to their homes as soon as possible. However, in the cases where patients are paying-residents of nursing or retirement homes, the sensitive issue of integrating mentally impaired and emotionally disturbed individuals with geriatric patients raises legitimate concerns, particularly because the former group also includes younger patients.

As authors Rose and Keigher states in, Managing Mental Health: Whose Responsibility?, there is an "emerging national uneasiness about the lack of fit between chronic mental illness and the acute care treatment model practiced in managed behavioral health care, because the care of severely mentally ill patients has been built on a different set of assumptions." (Rose & Keigher, 1996) They continue to discuss this issue but emphasize that there is a national trend to privatize the care of the mentally ill. "Despite the dearth of research and substantial questioning of the "goodness of fit" of managed care with chronically mentally ill people, States are busily forging ahead, crafting new initiatives to treat this population. To experiment with managed care for mental health services under Medicaid, States must apply for and receive a waiver under Section 1115 of Title XIX of the Social Security Act. These waivers require that research and demonstration be a part of the project but allows States to waive eligibility and HMO requirements and to have some non-covered services. As of July 1995, 11 States had waivers approved, nine States had applications pending, and eight were preparing waiver requests. States with approved waivers include Arizona, Florida, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oregon, Rhode Island, South Carolina, and Tennessee. These State demonstration projects differ in their eligibility requirements, benefits provided, managed care design, financing arrangements, and structure. Although these projects have generated only beginning empirical data for comparison, they illustrate national trends in State efforts to privatize mental health services." (Rose & Keigher, 1996)

Rose and Keigher conclude that these projects have huge implications for the treatment of the mentally ill. "The implications of this shift from public responsibility to publicly funded private responsibility for the care of people with mental illnesses are enormous. The shock waves will be felt by the people needing the care, by social workers in community mental health centers, and by state-level administrators of services." (ibid) Those affected will also be the social workers in mental heath practice and especially those practicing in local community health agencies, rather than those in private practice.

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